Several years ago, when I was chairman of the Surgical Quality Assurance Committee, the hospital medical director came to one of our meetings. We have a problem, he said. The Joint Commission on Accreditation of Hospitals had, on its recent inspection, given our hospital a list of criticisms, one of which involved unnecessary surgery. That, of course, got my attention, even though I've often said unnecessary surgery gets a bad rap: it's easier than the needed kind (nothing like disease to complicate things), and healthy patients generally do better than sick ones. NOTE: kidding.

The problem, it turns out, was not that they'd uncovered instances. It was that there was no requirement that surgeons include surgical indications (the reasons for doing a given operation) in the operative reports. We had six months to implement a solution: they'd be back to recheck at that time. OK, I said, we'll do it. Forget that it's stupid. Because if a surgeon is willfully going to do an operation he knows is unnecessary, he certainly'd have no compunction about lying into the record. Moreover, times had long since changed: if people see something fishy in the OR, they talk, they report, they get things changed. Nurses ain't stupid; and not only do they no longer stand up when the doctor walks into the room, they (rightfully) see themselves as advocates for patients. Not that doctors don't, of course.

So, no problem. There are published lists of indications for any given operation. Surgeons can dictate into the record why they're doing a thing, people in medical records can compare their reasons to those lists. Everybody's happy. (Being the passive aggressive type I'd often say things like: "operation: appendectomy; indication: appendicitis." Some operations pretty much go without saying. Or so one might believe.) We got the word to the surgeons, everyone complied. As stupid hospital rules go, this one was pretty benign, and even sensible, more or less.

Time: six months later. Place: SQAC (pronounced squawk) committee meeting. Speaker: the medical director, again. Saying, guys, they came back, and they don't like your system. It doesn't work. What do you mean, I ask. It's not working, he repeats. It's not finding unnecessary surgery. Long pause. VERY long pause. Dick, I say (it was his name, not a declaration). Does it occur to you that the reason we're not finding unnecessary surgery is that we're not DOING unnecessary surgery? C'mon, says Dick. The rest of the meeting is somewhat of a blur in my memory. The minutes of the meeting, assembled by the staff secretary, were tastefully discreet. Something like "discussion ensued." It's possible there was one less serviceable chair in the room at the end than there was at the beginning. There may have been suggestions made that, even for a surgeon, were anatomically impossible. Had they been, the minutes of the meeting, and the report of the inspectors would likely have required decontamination before handling again. I guess it boils down to this: regarding the suggestion that we come up with a better plan, I demurred.

Comments

Surgeons are freak animals. Either because I have the Youngest Child's attitude or because I'm full of shit, I've never been able to get along with one. Specialists of any kind make my flesh crawl, and they respond in kind.

Obviously this guy was right to fume, but there's something to be said for having these guys put it down in simple words and slow sentences. To cut into people's skin for a living, you have to have a sturdy, focused ego. Civilization chooses the best through competition, but that means these priestly guys spend their lives talking to each other in molecular shorthand and Latin. It's good if this paperwork compels them to talk in human terms... Their patients are human even if dim, and medicine is human enterprise.

They say hospitals handle pain much more effectively than just a few years ago. And the new practice throughout the industry is simply to ask "Are you in pain?"

Crid
at September 5, 2006 1:09 PM

I used to work at a vet and even they have rigid paperwork concerning exactly why surgery needs to be done. Perhaps it's because the entire bill is up to the owner, but every owner always had questions - it's surprising to see human doctors are revered enough to have no need for that kind of documentation. I mean, there have been thousands of surgeries that are for no reason (I can't remember where i read it, but there was an article about a young woman who was told she needed a hystorectomy and later found out - after the surgery - that she was confused with another patient).

Abby
at September 5, 2006 2:21 PM

Hmm, unecessary and quality. I have to wonder, how many of the procedures in question were for people not in a "managed care" plan. My point is that in most States, a MCP needs to be accredited, and they have care management staff and utilization staff. So if Dr. Frankenfuck wants to perform a hysterectomy on a man, it's caught. Many private insurances and most state welfare plans, have no medical management on the front end, and DO not have to be accredited.

Hmm, with State agencies, for example the one I live in, have several hundred thousand on the straight caid role, and no one watching, except some procedures, mainly transplants, sterilizations and abortions, it makes one wonder what tree quality should be really barking up.

sonja
at September 5, 2006 5:28 PM

Having no expertise about this at all, I'd assume the fear of malpractice suits and insane juries would keep doctors from doing surgeries for fun.